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International journal of cardiology 04/2013; · 7.08 Impact Factor
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ABSTRACT: Platelet dysfunction due to cardiopulmonary bypass (CPB) surgery increases the risk of bleeding. This study analyzed the effect of a phosphorylcholine (PC)-coated CPB circuit on blood loss, transfusion needs, and platelet function. We performed a prospective, randomized study at Strasbourg University Hospital, which included 40 adults undergoing coronary artery bypass graft surgery (CABG) (n = 20) or mitral valve repair (n = 20) using CPB. Patients were randomized either to PC-coated CPB or uncoated CPB (10 CABG patients and 10 mitral valve repair patients in each group). Blood loss and transfusion needs were evaluated intra- and postoperatively. Markers of platelet activation and thrombin generation were measured at anesthesia induction, at the beginning and end of CPB, on skin closure, and on days 0, 1, and 5. Comparisons were made by Student's t test or covariance analysis (significance threshold p < or = .05). Blood loss was significantly lower in the PC group during the first 6 postoperative hours (171 +/- 102 vs. 285 +/- 193 mL, p = .024), at the threshold of significance from 6-24 hours (p = .052), and similar in both groups after 24 hours. During CPB, platelet count decreased by 48% in both groups. There was no difference in markers of platelet activation, thrombin generation, or transfusion needs between the two groups. Norepinephrine use was more frequent in the control group (63% vs. 33%) but not significantly. PC-coating of the CPB surface reduced early postoperative bleeding, especially in CABG patients, but had no significant effect on platelet function because of large interindividual variations that prevented the establishment of a causal relationship.
The Journal of extra-corporeal technology 03/2012; 44(1):5-9.
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Pierre Sié,
Charles M Samama,
Anne Godier,
Nadia Rosencher, Annick Steib,
Juan V Llau,
Philippe Van der Linden,
Gilles Pernod,
Thomas Lecompte,
Isabelle Gouin-Thibault,
Pierre Albaladejo
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ABSTRACT: Direct oral anticoagulants (DOAs)--inhibitors of thrombin or factor-Xa--are expected to replace vitamin K antagonists in most of their indications. Patients receiving long-term treatment with DOAs are likely to be exposed to elective or emergency surgery or invasive procedures. Owing to the present lack of experience in such conditions, we cannot make recommendations, but only propose perioperative management for optimal safety regarding the risk of bleeding and thrombosis. DOAs may increase surgical bleeding, they have no validated antagonists, they cannot be monitored by simple standardized laboratory assays and their pharmacokinetics vary significantly between patients. Although DOAs differ in many respects, the proposals in the perioperative setting need not be specific to each. For procedures with low haemorrhagic risk, a therapeutic window of 48 hours (last administration 24 hours before surgery, restart 24 hours after) is proposed. For procedures with medium or high haemorrhagic risk, we suggest stopping DOAs 5 days before surgery to ensure complete elimination in all patients. Treatment should be resumed only when the risk of bleeding has been controlled. In patients at high thrombotic risk (e.g. those in atrial fibrillation with a history of stroke), bridging with heparin (low molecular-weight heparin, or unfractionated heparin, if the former is contraindicated) is proposed. In an emergency, the procedure should be postponed for as long as possible (minimum 1-2 half-lives) and non-specific antihaemorrhagic agents, such as recombinant human activated factor VIIa or prothrombin complex concentrates should not be given for prophylactic reversal due to their uncertain benefit-risk.
Archives of cardiovascular diseases 12/2011; 104(12):669-76. · 0.66 Impact Factor
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ABSTRACT: Epidural analgesia is the gold standard for post-thoracotomy pain relief but is contraindicated in certain patients. An alternative is paravertebral block. We investigated whether ropivacaine, administered through a paravertebral catheter placed by the surgeon, reduced postoperative pain.
In a randomized double-blind study, adult patients with a paravertebral catheter placed by the thoracic surgeon after thoracotomy were randomly assigned to receive through this catheter, either a 0.1 mlkg(-1) bolus of 0.5% ropivacaine, followed by a continuous infusion of 0.1 mlkg(-1)h(-1) for 48 h, or saline at the same scheme of administration. Patients also benefited from patient-controlled analgesia with intravenous morphine (bolus 1mg, lockout time 7 min), paracetamol, and nefopam. The primary endpoint was pain intensity on a visual analog scale at rest and on coughing. Secondary endpoints were total morphine consumption and side effects during the first 48 postoperative hours. Surgeons, anesthesiologists, and all the nurses and caring staff involved in this study were blinded. Solutions of saline and ropivacaine were prepared identically by the central pharmacy, without any possible identification of the product.
Forty-seven patients with contraindications to epidural anesthesia were included. There were no significant differences between the groups receiving ropivacaine and saline in terms of pain severity at rest and on coughing, mean postoperative morphine consumption (45.7 mg for ropivacaine, 43.2mg in controls), and incidence of morphine-related side effects (nausea and vomiting, urinary retention, pruritus, respiratory rate, and sedation).
Paravertebral block using a catheter placed by the thoracic surgeon was ineffective on postoperative pain after thoracotomy and did not confirm the analgesic effect that has been observed after percutaneous catheter placement. A direct comparison of these two placement methods is required.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2011; 40(4):902-6. · 2.40 Impact Factor
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ABSTRACT: Diagnostic and therapeutic endovascular stenting tended to expand in the last decade. The anesthetist may be asked to participate in the management of these patients with severe associated comorbidities complicating the delivery of anesthesia. This review describes current vascular stentings performed in the radiology suite and their relevant consequences interesting the anesthetist.
Most of these procedures can be performed under local anesthesia associated or not with moderate sedation. Carotid stenting is as well tolerated as carotid surgery but those selected patients who may benefit from it are not clearly identified. Endovascular stenting of the aorta avoids major surgical trauma and decreases its consequences. The procedure requires light anesthesia but careful monitoring. Prior thoracic aortic replacement and the length of zone numbers covered by the stent graft are risk factors for spinal ischemia that may lead to paraplegia. Cerebrospinal fluid drainage, evoked potential, and S100 beta monitoring may help to prevent this complication or detect it earlier. Transjugular intrahepatic portosystemic shunt is efficient in treating acute variceal bleeding and for secondary prevention. Postoperative encephalopathy represents the main postprocedural complication.
Literature review provides little information about anesthetic management of extracranial endovascular stentings. Knowledge of indication and consequences is mandatory for anesthetists in charge of these patients.
Current opinion in anaesthesiology 08/2008; 21(4):519-22.
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ABSTRACT: Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid.
In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day.
Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups.
After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.
Anesthesia and analgesia 08/2007; 105(1):238-44. · 3.08 Impact Factor
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ABSTRACT: Preoperative interruption of oral anticoagulants is not essential for every procedure performed during surgery or outside of the operating room. The thrombotic risk associated with preoperative treatment interruption is too often overestimated. In practice, only patients at elevated risk should receive bridge therapy with standard or low-molecular-weight heparin. Patients with an INR less than 2 can undergo numerous surgical procedures. In the case of an immediate emergency in a patient treated with oral anticoagulants, perfusion with prothrombin complex is recommended. It is very effective and entails few risks. Vitamin K must be used as a complement, or alone in less urgent case, at a low-dose (< 5 mg) and preferably orally. The phase of treatment resumption with a postoperative double treatment of heparin and oral anticoagulants must last long enough to avoid any thrombosis.
La Presse Médicale 06/2007; 36(6 Pt 2):1024-8. · 0.67 Impact Factor
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Liver Transplantation 09/2006; 12(8):1301-2; author reply 1303-4. · 3.39 Impact Factor
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ABSTRACT: To review laboratory investigations required for the diagnosis of a constitutional or acquired defect of hemostasis before surgery, or during the perioperative period in context of rapid evolution and possible therapeutic adjustment.
A review of the literature.
Systematic preoperative screening is poorly efficient. It should be restricted to patients selected on clinical history and physical examination. Intra- and postoperative investigation is oriented by the clinical circumstances. In most instances, laboratory investigation is organized as hierarchical steps, the first one including a platelet count, a prothrombin time and activated partial thromboplastin time. According to the results of these assays and to the clinical circumstances, further tests specific of primary hemostasis, coagulation or fibrinolysis are performed. Point of care (POC) monitoring has been developed more recently for the investigation of a perioperative bleeding. Several tests examine platelet functions, others measure whole blood activated partial thromboplastin time or prothrombin time and some explore global hemostasis, allowing the detection of excessive fibrinolysis. Point of care testing provides a rapid and valuable answer but, if one accepts the monitoring of unfractionated heparin during extracorporeal circulation, most assays have not been properly validated.
The investigation of hemostasis at the central laboratory and POC testing have distinct objectives. The utility of the former for the diagnosis and the adjustment of therapeutics have been well demonstrated. In contrast, the experience with POC testing is relatively recent, and its utility for patient management remains to be demonstrated in proper clinical trials.
Canadian Journal of Anaesthesia 07/2006; 53(6 Suppl):S12-20. · 2.35 Impact Factor
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ABSTRACT: As the number of patients taking vitamin K antagonists (VKA) is growing, the clinician is increasingly faced with having to make decisions regarding anticoagulation therapy before, during and immediately after surgery. In this article we review the indications for VKA and assess their use in the perioperative period based on available pharmacological and clinical data.
An on-line computerized search of Medline was conducted limited to English and French language articles. The bibliographies of relevant articles and additional material from other published sources were retrieved and reviewed.
Assessment of patients taking VKA who need surgery must include three factors: 1) the indication for anticoagulation, which determines the thromboembolic risk; 2) the pharmacokinetics of VKA, which determine the moment at which treatment should be discontinued; and 3) the type of surgery, which determines the hemorrhagic risk. Some patients will need to stop VKA treatment and start a substitution or "bridging" anticoagulant therapy, such as unfractionated heparin or low molecular weight heparin, prior to and after surgery. In patients requiring emergency surgery, prothrombin complex concentrate can be used to improve coagulation and is preferable to, although more expensive than fresh frozen plasma.
For the perioperative setting, further studies are required to determine the optimal substitution ("bridging") regimen and the clinical circumstances that necessitate substitution therapy.
Canadian Journal of Anaesthesia 07/2006; 53(6 Suppl):S113-22. · 2.35 Impact Factor
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Journal of Cardiothoracic and Vascular Anesthesia 07/2002; 16(3):344-6. · 1.64 Impact Factor
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ABSTRACT: Pediatric strabismus surgery leads to undesirable intraoperative and postoperative side effects that include pain, postoperative nausea and vomiting (PONV), and oculocardiac reflex (OCR). We hypothesized that subtenon anesthesia performed before the start of surgery and combined with general intravenous anesthesia would reduce these adverse effects.
Forty children (2.5 to 6 years of age, ASA status I to II) were prospectively randomized to receive either subtenon bupivacaine 0.5% or a saline injection before the beginning of surgery in a double-blind manner. Perioperative analgesic requirements, pain scores (CHEOPS scale), hemodynamics, and incidence of OCR and PONV were compared.
Postoperative pain scores were lower (P < .001) at removal of the laryngeal mask and 30 minutes later in the bupivacaine group. Intraoperative and postoperative analgesic requirements were significantly reduced in this group (P < .01). The incidence of OCR and PONV were also significantly decreased (P < .01). Intraoperative values of blood pressure were significantly higher in the saline group at 20 minutes (P < .02).
We conclude that preoperative subtenon bupivacaine 0.5% compared with a saline injection contributed to reduction of perioperative pain and undesirable side effects in pediatric strabismus surgery performed under general anesthesia.
Regional Anesthesia and Pain Medicine 30(5):478-83. · 4.08 Impact Factor
